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Clinical Characteristics and Visual Outcomes in Infectious Scleritis: a Review Emeline Radhika Ramenaden George Washington University

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Clinical Characteristics and Visual Outcomes in Infectious Scleritis: a Review Emeline Radhika Ramenaden George Washington University Himmelfarb Health Sciences Library, The George Washington University Health Sciences Research Commons Ophthalmology Faculty Publications Ophthalmology 2013 Clinical characteristics and visual outcomes in infectious scleritis: A review Emeline Radhika Ramenaden George Washington University Veena Rao Raiji George Washington University Follow this and additional works at: http://hsrc.himmelfarb.gwu.edu/smhs_ophthalm_facpubs Part of the Ophthalmology Commons Recommended Citation Ramenaden, E.R., Raiji, V.R. (2013). Clinical characteristics and visual outcomes in infectious scleritis: A review. Clinical Ophthalmology, 7, 2113-2122. This Journal Article is brought to you for free and open access by the Ophthalmology at Health Sciences Research Commons. It has been accepted for inclusion in Ophthalmology Faculty Publications by an authorized administrator of Health Sciences Research Commons. For more information, please contact [email protected]. Clinical Ophthalmology Dovepress open access to scientific and medical research Open Access Full Text Article REVIEW Clinical characteristics and visual outcomes in infectious scleritis: a review Emeline Radhika Ramenaden Abstract: Infection is a very important but rare cause of scleritis, occurring in about 5%–10% Veena Rao Raiji of all patients presenting with scleral inflammation. However, due to the similarity of its presentation, infectious scleritis is often initially managed as autoimmune, potentially further Department of Ophthalmology, George Washington University, worsening its outcome. The overall visual outcome in infectious scleritis is generally worse Washington, DC, USA than its autoimmune counterparts, perhaps because of the delay in diagnosis or because of the aggressive nature of associated microbes. Thus, there is a definite need for insight into the diagnostic approach and treatment options for this ocular disease process. Several studies and case reports have been published in recent years that have provided useful information regarding the presenting clinical features and etiologic microbial agents in infectious scleritis. This review summarizes the important findings in the literature that may aid in differentiating infectious scleritis from other etiologies, including predisposing factors, microbe-specific characteristics, diagnostic tools, treatment modalities, and outcomes. Keywords: infectious scleritis, Pseudomonas, necrotizing scleritis, abscess Background Scleritis is a state of ocular inflammation with a wide spectrum of clinical presentations and etiologic factors (Table 1). Specific etiologies of scleritis, varying from idiopathic to autoimmune to infectious, portend variable disease severity and outcome. Infection is an important but rare cause of the scleritis, occurring in about 5%–10% of all cases.1 However, due to the similarity of its presentation, infectious scleritis is often initially managed as autoimmune, potentially worsening its outcome. The overall visual outcome in infectious scleritis is generally worse than its autoimmune counterparts, perhaps because of this delay in diagnosis or because of the aggressive nature of associated microbes. Recent studies have identified specific inciting factors for infectious scleritis. Not surprisingly, these factors are typically surgery, most commonly pterygium surgery but also excisions of conjunctival neoplasms, cataract surgery, vitreoretinal surgeries, and glaucoma surgeries.2–4 Paula et al and Hodson et al report that the use of concomi- tant radiation or mitomycin C is also a risk factor.2,5 Trauma, especially with introduction of organic material to the ocular surface or self-inoculation from a distant site on the Correspondence: Emeline Radhika 6 Ramenaden body is also a significant inciting factor. In isolated cases, immunosuppression due to Department of Ophthalmology, human immunodeficiency virus or chemotherapy, may be a risk factor for spontane- George Washington University, ous cases of infectious scleritis.2,7,8 Interestingly, Meyer et al reported an individual 2150 Pennsylvania Ave, NW, Suite 2A, Washington, DC 20037, USA case of spontaneous infectious scleritis without any such prior history that revealed Tel +1 202 741 2800 Pseudomonas aeruginosa resistant to 4th generation fluoroquinolones, indicating the Fax +1 202 741 2805 Email [email protected] importance of considering infectious etiologies despite the lack of leading history.9 submit your manuscript | www.dovepress.com Clinical Ophthalmology 2013:7 2113–2122 2113 Dovepress © 2013 Ramenaden and Raiji. This work is published by Dove Medical Press Ltd, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further http://dx.doi.org/10.2147/OPTH.S37809 permission from Dove Medical Press Ltd, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Ltd. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Ramenaden and Raiji Dovepress Table 1 Types of scleritis Another known characteristic of infectious scleritis is Anterior-diffuse Greater than 50% contiguous scleral its sometimes delayed presentation, occurring months to involvement. Associated with systemic years after ocular surgery or trauma. Jain et al proposed that disease. Generally in women 40–70 years conjunctival and tear film alterations may expose underly- old or men 30–60 years old. Rare in the young and the very old. ing necrotic scleral collagen to microorganisms and allow Anterior-nodular Distinct nodules present. Associated with localization, adherence, colonization and invasion.1 Microbes isolated disease. Both sexes generally can then remain dormant within the sclera for years without involved, 40–60 years old. Anterior-necrotizing Scleral necrosis with scleromalacia. inciting an inflammatory response, making the diagnosis of (with inflammation) Associated with systemic disease. infectious scleritis in these cases quite difficult. It remains Generally in women in their 40s. unclear why these infections may be reactivated after such Anterior-necrotizing Scleral necrosis without scleromalacia. 12 (without inflammation) Usually associated with systemic disease. long periods of latency. Generally in women, 35–75 years old. According to one large retrospective study by Hodson Posterior scleritis Usually associated with anterior scleritis. et al, the median age of the patients at diagnosis of infec- Generally in women in their 60s. Diagnosis tious scleritis is 70 years old.2 Most studies reveal an older made using clinical and ultrasound findings. Infectious scleritis Generally necrotizing. Can have anterior population, suggesting that age may hold some significance and posterior involvement. Scleral ulcers in the diagnosis of infectious scleritis.2,13,14 Additionally, the with calcific plaque at the base and time from an identifiable inciting event to the presentation of microabscesses. Tissue extension beyond obvious clinical findings.* scleritis can range in 0 days up to 36 years, generally longer Notes: *Though infectious scleritis can present in many ways, these are the unique in postsurgical patients than the post-nonsurgical trauma clinical findings found most commonly in this review. Data from Raiji et al,45 and patients, with the longest latency period reported occurring Watson and Hayreh.46 after a history of pterygium surgery.2,10 While postoperative worsening of scleritis has been well In all cases of infectious scleritis, P. aeruginosa is the reported in those with preexisting autoimmune scleritis, a most common infectious agent.1,2 Additional identified concomitant infectious etiology is much less common. The microbes include Nocardia, Aspergillus, Fusarium, Candida, similarities in presentation between autoimmune and infec- Beauveria, Stenotrophomonas, Streptococcus, Staphylococ- tious scleritis often delays diagnosis. Infectious scleritis cus aureus (especially of the methicillin-resistant type), after pterygium surgery with adjunctive β-radiation and Serratia, Enterobacter, Achromobacter, Propionibacterium, mitomycin C has been well established.2,11,12 Several reasons Haemophilus, Alcaligenes, mycobacteria, and herpes viridae. may exist for this association. Meallet proposed in 2006 that In some cases, coinfections have been reported.2,15 Although the use of adjunctive therapies such as these are likely to com- P. aeruginosa as well as other bacterial and viral etiologies promise the integrity of episcleral conjunctival vessels and are most common in developed countries, fungi and Nocardia underlying tissue, thus inhibiting adequate wound healing and are relatively more prevalent in developing countries, perhaps leaving the sclera vulnerable to infection. He further hypoth- due to humid climates and increased exposure to soil.1 esizes that surgical techniques such as leaving bare sclera Retinal surgeries such as vitrectomy, scleral buckling exposed or excessive use of cautery, as well as poor contact lens with intrascleral fixation, and epiretinal membrane peel hygiene or nonhealing epithelial defects may all contribute.12 procedures have been associated with acid-fast organisms, P. aeruginosa, the most common agent in infectious scleritis, such as Mycobacterium chelonae, more so than anterior seg- utilizes neutrophil-activated collagenases to destroy
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